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Homebirth and Postpartum Hemorrhage

Practice Variation in Cesarean Rates: Not Due to Maternal Complications
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients.  This analysis shows that:

    Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
    Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
    Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.

Tips for Choosing a Care Provider - great overview! from Henci Goer

First, it's important to know that the most common cause of postpartum hemorrhage is overly aggressive fiddling with the placenta before it detaches normally on its own. This is common in the hospital, where the attendant must stay until the placenta is delivered. Although most placentas deliver promptly (15 or 20 minutes), some take a little longer, and obstetricians aren't always interested in hanging around waiting for the placenta. So they start "fiddling with the fundus", trying to rub up a contraction while tugging on the umbilical cord. This often leads to partial separation, which can cause postpartum hemorrhage.

At a homebirth, the midwives have to stay around for a couple of hours anyway, until everything is clearly stable, so it's not a big deal to wait for the placenta to do its thing in its own time, which usually results in a cleaner separation and less bleeding. The midwives still have to keep an eye on the mom, but they can do this while doing the newborn exam, writing up their charts, cleaning up, whatever.

The options for managing a postpartum hemorrhage at home are pretty much the same as in the hospital. (Exceptions: The management of last resort is a hysterectomy. You can't do that at home.)

At a homebirth, it's completely reasonable to deliver the placenta in a standing position. This tends to deliver the placenta quickly and also empties the uterus of blood or clots so that the uterus can clamp down quickly and stop the bleeding.

[Quick review of postpartum hemorrhage - when the placenta separates, it leaves a "wound" the same size (about the size of a salad plate) on the inside of the uterus. The design of birth is very cool - the criss-cross design of the muscle fibers in the different layers of the uterus creates a "living ligature" for the blood vessels leading to the "wound". So the uterus stops its own bleeding. This process is inhibited when there's something keeping it from contracting as small as possible. This is typically either a full bladder or blood or clots still inside the uterus. It's hard to get them out when a woman is lying on her back, other than by "massaging" the uterus, which can sometimes be an overly aggressive pounding of the mother's abdomen. ]

It's very difficult to get a postpartum mom in a standing position in the hospital because the beds tend to be difficult to get in and out of, so it's almost unheard of to see a standing placental delivery in the hospital. It's too bad that this simple prevention/treatment of postpartum hemorrhage isn't an option in the hospital. (Note - the same limitations also make shoulder dystocia more dangerous in the hospital.)

In addition, a homebirth scenario is more likely to include a newborn baby at the breast, which causes contractions to bring the placenta more quickly and to assist the uterus in clamping down and stopping the bleeding. (After all, the baby's sucking stimulates the production of oxytocin, the original and natural version of synthetic pitocin.)

In case of a true, life-threatening postpartum hemorrhage at a homebirth, midwives use pretty much the same techniques as in the hospital - compressing the uterus and administering pitocin.

In the very rare event of a bleeding disorder which will not respond to normal management, you can manually compress the uterus between two hands while you transport to the hospital for surgery or administration of blood products.

In California, licensed midwives are IV certified so that we can administer IV fluids to prevent or treat shock while waiting for the ambulance.

In rare cases, the perineal tearing may be the source of the postpartum hemorrhage. If it was beyond the suturing abilities of the midwife, then you'd control the bleeding and treat for shock while you transport to the hospital. (Really, though, it's very unlikely that a perineal tear would cause life-threatening bleeding.)



This Web page is referenced from other pages containing related information about Third Stage and Homebirth Safety/Advocacy

 




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